United States District Court, D. Montana, Great Falls Division
MORRIS UNITED STATES DISTRICT COURT JUDGE.
Tawater filed a Complaint against Health Care Services
Corporation d/b/a Blue Cross and Blue Shield of Montana
(“BCBSMT”) on February 26, 2018. (Doc. 1.)
Tawater alleges underpayment of medical benefits under an
employee welfare benefit plan (“the Plan”)
administered by BCBSMT. Id. at 2. The Employee
Retirement Income Security Act of 1974 (“ERISA”)
governs the Plan.
filed the instant Motion to Dismiss on April 30, 2018. (Doc.
12.) The Court conducted a motion hearing on June 25, 2018.
(Doc. 35.) The Court requested both parties submit
supplemental briefing on the effect that assignment under the
Plan has on Tawater's standing to sue BCBSMT.
Id. Tawater filed her supplemental brief on July 6,
2018. (Doc. 36.) BCBSMT filed its brief on July 16, 2018.
was admitted to Mercy Medical Center in Williston, North
Dakota on July 9, 2014. (Doc. 27 at 7.) The attending
emergency room physician determined that Tawater needed to be
transferred to Trinity Hospital in Minot, North Dakota.
Id. Guardian Flight, Inc. (“Guardian”)
transported Tawater from Williston to Minot on July 10, 2014.
(Doc. 28-2 at 2.) Guardian is an out-of-network medical
transport provider. (Doc. 13 at 3.) Guardian billed Tawater
$43, 881.92 for the transport from Williston to Minot. (Doc.
28-3 at 2.)
Plan administered by BCBSMT insured Tawater at all relevant
times. (Doc. 13 at 4.) The Plan required Tawater to submit
her transport claim to BCBSMT “no later than 12 months
from the date of service.” (Doc. 13-1 at 50.) BCBSMT
sent Tawater's father an Explanation of Benefit
(“EOB”) on July 28, 2014. (Doc. 28-3 at 2.) The
EOB indicated that the total allowed amount for the transport
under the Plan was $13, 222.44. Id. The EOB noted
that Tawater remained responsible to Guardian for the unpaid
amount of $30, 659.48. Id.
signed Guardian's transport agreement before the
transport on July 10, 2014. (Doc. 28-2 at 2.) The transport
agreement assigned Tawater's right of payment to
Guardian. Id. Tawater's transport agreement with
Guardian states, in pertinent part, as follows: “I
request that payment of authorized Medicare, Medicaid or
other insurance benefits to be made on my behalf to Guardian
Flight. I assign Guardian Flight all right, title and
interest in all benefit plans from which my dependents or I
are entitled to recover.” Id.
Plan permitted Tawater to assign her right of payment to a
medical provider. The Plan's assignment provision reads
All Plan benefits are payable to a Participant, Qualified
Beneficiary or Alternate Recipient, whichever is applicable.
All or a portion of the benefits payable by the Plan may, at
the Covered Person's option and unless the Covered person
requests otherwise in writing not later than the time of
filing the claim, be paid directly to the health care
provider rendering the service, if proper written assignment
is provided to the Plan. No. payments will be made to any
provider of services unless the Covered Person is liable for
(Doc. 13-1 at 106.)
Plan likewise established a statute of limitations period.
The Plan's limitations provision provides as follows:
No action at law or equity will be brought to recover on the
Plan prior to the expiration of sixty (60) days after proof
of loss has been filed in accordance with the requirements of
the Plan, nor will such action be brought at all unless
brought within three (3) years from the expiration of the
time within which proof of loss is required by the Plan.
Id. (emphasis added).
July 28, 2014, EOB explained that Tawater or her authorized
representative could “appeal the decision within 180
days from the receipt” of the EOB if Tawater disagreed
with the “denial or partial denial of a claim.”
(Doc. 29-3 at 3.) Guardian filed a timely appeal of
BCBSMT's adverse benefit determination on September 15,
2014. (Doc. 28-4 at 2.) BCBSMT denied Tawater's appeal on
October 24, 2014. (Doc. 29-6 at 2.) Tawater, through her
counsel, subsequently sent BCBSMT a letter restating
Tawater's appeal on February 1, 2017. (Doc. 28-9 at 2.)
BCBSMT denied Tawater's February 1, 2017, appeal as
untimely. (Doc. 28-10 at 2.)
motion to dismiss under Rule 12(b)(6) tests the legal
sufficiency of a complaint. Navarro v. Block, 250
F.3d 729, 732 (9th Cir. 2001). The Court “must take all
allegations of material fact as true and construe them in the
light most favorable to the nonmoving party” when
evaluating a Rule 12(b)(6) motion. Kwan v. Sanmedica
Int'l, 854 F.3d 1088, 1096 (9th Cir. 2017) (quoting
Turner v. City & County of San Francisco, 788
F.3d 1206, 1210 (9th Cir. 2015)). The complaint must allege
sufficient facts to state a plausible claim for relief to
survive a motion to dismiss. Taylor v. Yee, 780 F.3d
928, 935 (9th Cir. 2015).
courts generally view “with disfavor” Rule
12(b)(6) dismissals. Rennie & Laughlin, Inc. v.
Chrysler Corp., 242 F.3d 208, 213 (9th Cir. 1957).
“A case should be tried on the proofs rather than the
pleadings.” Id. The Court may consider
documents on a motion to dismiss “whose contents are
alleged in the complaint and whose authenticity no party
questions, but which are not physically attached to the
[plaintiff's] pleading.” Branch v.
Tunnell, 14 F.3d 449, 454 (9th Cir. 1994).
Statute of Limitations Provision
argues that Tawater filed her Complaint after the Plan's
three-year statute of limitations period had expired. (Doc.
13 at 10.) The Plan required Tawater to appeal her adverse
benefit determination within 180 days of receiving the EOB.
(Doc. 34 at 10.) Tawater alleged that she received the EOB in
July 2014. Id.
argues that the Plan required Tawater “to provide
notice that she contested the determination” by January
of 2015. Id. BCBSMT claims that Tawater's
statute of limitation period expired three years after this
notice-in January of 2018. Id. BCBSMT contends that
Tawater's filing of her Complaint in February of 2018-one
month after the limitations period had expired-bars
consideration of her claims. Id.
agrees that the Plan provides a three-year statute of
limitations period to file a complaint. (Doc. 27 at 28.)
Tawater notes, however, that the Plan's statute of
limitation period accrues at “the expiration of the
time within which proof of loss is
required.” Id. (citing Doc. 13-1 at 106)
(emphasis added). Tawater interprets “the expiration of
the time within which proof of loss is required, ” as
used in the Plan, as “no later than 12 months after the
date of service.” (Doc. 27 at 28) (citing Doc. 13-1 at
transported Tawater on July 10, 2014. (Doc. 27 at 28.)
Tawater contends that the Plan allowed her to file her proof
of loss until July 10, 2015. Id. Tawater contends
that the expiration of this July 10, 2015, date in which to
file her proof of loss triggered the running of the
Plan's three-year statute of limitations period.
Id. at 28-29. Tawater contends, under this
interpretation, that the statute of limitations period should
have expired on July 10, 2018. Id. at 29. Tawater
argues that she timely filed her Complaint on February 26,
claimant generally must file her claim within the statute of
limitations period. Heimeshoff v. Hartford Life &
Acc. Ins. Co., 571 U.S. 99, 105 (2013). Statutes of
limitations generally “begin to run when the cause of
action accrues- that is when the plaintiff can file suit and
obtain relief.” Id. (quoting Bay Area
Luandry and Dry Cleaning Pension Trust Fund v. Ferbar Corp.
of Cal., 522 U.S. 192, 201 ...